Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The advance directive impact of PET scans in vegetative states

Ruth Macklin, PhD
Physician
June 13, 2014
Share
Tweet
Share

One typically thinks of advances in medical science and technology as having unalloyed benefits. The ability to cure illness, the mitigation of pain and the possibility of making diagnoses that are more accurate are some of the uncontroversial results of medical progress. Yet as a new study of vegetative states demonstrates, such advances can raise ethical quandaries for physicians and the families of patients diagnosed as vegetative.

The study, conducted in Belgium and published in the British medical journal Lancet, showed that using the brain-imaging technique known as positive emission tomography (PET) provided a more accurate neurological assessment than other techniques, such as magnetic resonance imaging. The assessment provides more information about “minimally conscious” states, originally thought not to exist in such patients. Evidence from recent research had demonstrated the existence of minimal consciousness in vegetative patients, but without the details that emerged in the Belgian study. The latter revealed that not only do patients who are minimally conscious have some level of awareness or responsiveness, but they may also have some chance of improving and regaining higher levels of consciousness.

More information, more quandaries

Why does this new research pose ethical quandaries? Aside from the acknowledgment by a researcher in the Belgian study that the diagnostic technique is not ready for routine use, a bigger problem is the uncertainty in its ability to predict significant improvement or recovery. This can lead to “false positives” — diagnoses that show minimal consciousness and a prospect of improvement in brain function when that will not occur. This situation produces uncertainty among medical experts and families who are hopeful that their loved ones will recover cognitive function. As the Belgian researcher stated, “We shouldn’t give these families false hope.”

In such circumstances, physicians and families may be unlikely to remove life supports even after significant time has elapsed, creating anguish about whether and when to “pull the plug.” Until recently, the problem of uncertainty was that of “false negatives”: diagnoses that patients in a vegetative state had no consciousness at all when, in fact, they may have been minimally conscious. With the new study, uncertainty about eventual improvement looms as a barrier to timely decision making. And lingering uncertainty often is worse for people who have to make decisions than receiving a bad but definitive prognosis.

Some controversy still exists regarding the ethics of removing ventilators or artificial feeding from patients diagnosed as having no chance of recovery. Although families’ willingness to have life supports removed from their relatives is now more common than refusal, opposition remains strong among members of some religious groups. The new evidence may lead to changes in families’ agreement to terminate life-sustaining treatment. And while the use of PET scans for this purpose is not ready for prime time, as further studies confirm the results people may begin to demand this diagnostic technique on a routine basis.

Should advance directives be updated?

Advance directives (formerly called “living wills”) — instructions people make while fully competent about what they would want to happen if they were to lose decisional capacity — have been made by only a minority of people in the U.S. Yet among those of us who have executed such documents, the question arises: Should we consider revising them in light of this new research? The standard wording in some advance directives says: “I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment … if I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness.” (This choice not to prolong life appears in the New York State template for the advance directive.) Should such standard wording in forms provided by states now be amended to include mention of “minimally conscious states”?

The other option on the form — the choice to prolong life — says: “I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.” If and when the use of PET diagnoses of vegetative states becomes an accepted health care standard, will people who make advance directives change their decisions?

These questions lie in the future. But as many in the field of bioethics urge, it is best to begin thinking about and discussing future medical scenarios before they are upon us.

Ruth Macklin is a professor, department of epidemiology and population health, Albert Einstein College of Medicine, Bronx, NY. She blogs at The Doctor’s Tablet.

Prev

Physician well-being is essential to optimal patient care

June 13, 2014 Kevin 11
…
Next

Have ADHD diagnoses reached a tipping point?

June 13, 2014 Kevin 1
…

Tagged as: Neurology

Post navigation

< Previous Post
Physician well-being is essential to optimal patient care
Next Post >
Have ADHD diagnoses reached a tipping point?

ADVERTISEMENT

More by Ruth Macklin, PhD

  • Is the National Institutes of Health stifling academic freedom?

    Ruth Macklin, PhD
  • How can we fix the research bias from industry sponsorship?

    Ruth Macklin, PhD
  • The erosion of informed consent in medical research

    Ruth Macklin, PhD

Related Posts

  • How social media can advance humanism in medicine

    Pooja Lakshmin, MD
  • 3 ways to advance the credibility of online health information

    Robert Pearl, MD
  • The ultimate in patient empowerment: advance care planning

    Patricia McTiernan
  • How hospitals can impact generic drug companies

    Mark Kelley, MD
  • Successfully navigating advance directives to choose your best one

    Althea Halchuck, EJD
  • a desk with keyboard and ipad with the kevinmd logo

    The impact of removing numerical scores from USMLE Step 1

    Cory Michael, MD

More in Physician

  • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

    Yousuf Zafar, MD
  • The hidden rewards of a primary care career

    Jerina Gani, MD, MPH
  • Why doctors regret specialty choices in their 30s

    Jeremiah J. Whittington, MD
  • 10 hard truths about practicing medicine they don’t teach in school

    Steven Goldsmith, MD
  • How I learned to love my unique name as a doctor

    Zoran Naumovski, MD
  • What Beauty and the Beast taught me about risk

    Jayson Greenberg, MD
  • Most Popular

  • Past Week

    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • IMGs are the future of U.S. primary care

      Adam Brandon Bondoc, MD | Physician
    • Why I left the clinic to lead health care from the inside

      Vandana Maurya, MHA | Conditions
    • How doctors can think like CEOs [PODCAST]

      The Podcast by KevinMD | Podcast
    • A surgeon’s testimony, probation, and resignation from a professional society

      Stephen M. Cohen, MD, MBA | Physician
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • How a doctor defied a hurricane to save a life

      Dharam Persaud-Sharma, MD, PhD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
  • Recent Posts

    • Affordable postpartum hemorrhage solutions every OB/GYN can use worldwide [PODCAST]

      The Podcast by KevinMD | Podcast
    • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

      Yousuf Zafar, MD | Physician
    • Psychiatrist tests ketogenic diet for mental health benefits

      Zane Kaleem, MD | Conditions
    • The hidden rewards of a primary care career

      Jerina Gani, MD, MPH | Physician
    • Why physicians should not be their own financial planner

      Michelle Neiswender, CFP | Finance
    • Why doctors regret specialty choices in their 30s

      Jeremiah J. Whittington, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • IMGs are the future of U.S. primary care

      Adam Brandon Bondoc, MD | Physician
    • Why I left the clinic to lead health care from the inside

      Vandana Maurya, MHA | Conditions
    • How doctors can think like CEOs [PODCAST]

      The Podcast by KevinMD | Podcast
    • A surgeon’s testimony, probation, and resignation from a professional society

      Stephen M. Cohen, MD, MBA | Physician
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • How a doctor defied a hurricane to save a life

      Dharam Persaud-Sharma, MD, PhD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
  • Recent Posts

    • Affordable postpartum hemorrhage solutions every OB/GYN can use worldwide [PODCAST]

      The Podcast by KevinMD | Podcast
    • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

      Yousuf Zafar, MD | Physician
    • Psychiatrist tests ketogenic diet for mental health benefits

      Zane Kaleem, MD | Conditions
    • The hidden rewards of a primary care career

      Jerina Gani, MD, MPH | Physician
    • Why physicians should not be their own financial planner

      Michelle Neiswender, CFP | Finance
    • Why doctors regret specialty choices in their 30s

      Jeremiah J. Whittington, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...